Pie, meet Sky

A friend sent me a link to an article from emsresponder.com. The link took me through http://www.emstelemedicine.com/ which is the website of the company selling this technology.

My friends know that I’m sort of a technogeek. I have more electronic gadgets than you can shake a stick at. I should love this kind of thing, but I don’t. To me, it seems like a technological solution in search of a problem to solve.

I’m going to pick a few quotes from the article and comment. I urge you to read the entire thing and decide for yourself.

The call management protocol identifies this as an Alpha call, and instead of a BLS ambulance being dispatched, a light-duty truck with telemedicine capabilities staffed by two basic EMTs is dispatched. The team arrives on scene and assesses the patient’s condition. They determine that the burn is not severe, easily treatable on-scene, and that the patient remains capable of providing for himself/herself at home.

If the crew can determine all of that before setting up the whiz bang telemedicine rig, why do they need to bring the doctor in at all? You can bet that if the fecal matter hits the fan, the doctor is going to dump (no pun intended) responsibility right back on the crew.

By using their telemedicine system, the EMTs are able to provide a “virtual” visit with an ED physician, who examines the patient and, after a face-to-face conversation, convinces the patient that everything needed has been done and that there is no reason to go to the emergency department.

I don’t know about the hospitals in your area, but the ones in my area don’t have doctors sitting idly by waiting for the virtual telephone to ring. Residents, fellows, and attendings are buried in paperwork for patients that are in the ED. Where are they going to find time to do a “virtual” visit and then do documentation. The recording is NOT going to be sufficient for any purposes including “potential reimbursement” whatever that might be. Nor is it going to help litigation. In fact a friend of mine who is both a lawyer and a paramedic says that unlike with police in car video, this has the potential to increase, not decrease liability.

Furthermore, with the aid of follow-up telephonic care, the patient will be able to provide on-going self-care for the injury.

From where? Who is going to pay for the follow up care?

Best of all, reimbursement could be less than it would for a traditional call and still cover every aspect of the episode.

WHAT reimbursement? Right now reimbursement is pretty much based on transport, not treatment without transport. Would reimbursement, if the laws and regulations were changed to allow it, cover the cost of sending an EMS crew to a scene? How about the hospital? Many hospital EDs are staffed not by hospital employees, but by physicians groups that bill separately for each patient treated. How much payment is going to be authorized for a “home visit” that isn’t an in person visit?

The liability issues associated with treat and release are difficult to resolve because they are real. The cost of a judgment error by a medic is potentially high, and to many unacceptably high, both monetarily as well as professionally. To address these concerns, there is much EMS can do to insure the delivery of first quality care and “placing patients first” by means of training and sound treatment protocols. These are things that a highly professional, well organized EMS operation can manage — particularly if the issues of public expectation and reimbursement are resolved

Good point, especially the training and sound protocol parts. If a system does that sort of thing, I again have to wonder if a live on line consult with a doctor is needed. If a consult is needed, does it need audio and video of the patient?

The authors/proponents don’t even touch the consent issues that will exist in some states. Some states, such as Massachusetts, require all parties being audio taped to be advised of that fact and give informed consent. How will that work, I wonder.

Not to mention that some people won’t want complete strangers to set up cameras and microphones in their houses or places of business. There is that whole expectation of privacy thing.

Nor do the authors bring up any cost issues. At a minimum the ambulance is going to need some sort of constant data connection. Or as near to constant as the state of the art allows. Maybe in Tucson, which is pilot city for this, that might be free, but it’s neither free nor available everywhere. Citywide WiFi networks have turned out to be much more expensive and difficult to build and operate than was thought five years ago. Wireless (cell phone) connectivity costs anywhere from $50.00 per month, per device, and up. Who is going to maintain the equipment? Believe me, any technology that is not Mil Spec ruggardized, and most that is, will break in the 24/7 high use world of EMS.

The old joke is if you give an EMT, medic, or fire fighters, two bowling balls, they will lose one and break the other. And then claim that it happened on their days off. So, you’re going to need a full time tech support person or maybe you can add it to the duties of your existing IT staff. I’m sure they’d love that, after all they just sit around shopping on Ebay anyway.

In a unionized work force the terms “change in conditions of employment”, “compensation adjustment”, and “we aren’t going to do it without negotiating first” are going to come up. In fact, I’m told by my lawyer/paramedic friend that the TFD medics have flat out refused to use the system.

I’d like to see what the per ambulance and per ED costs are for this. I have to wonder if you add up the one time and annual cost of this system if it wouldn’t be cheaper to add a couple of ambulances to the complement.

I won’t even go into the utility and return on investment of having an all ALS system for “emergency” calls and relegating BLS to “non emergency” calls. That’s a debate for a whole different day.

There is definitely a place for technology in EMS, especially in the realm of documentation, risk management, billing, QA/QI, and research. This just isn’t it. This just seems like really expensive technology that will end up sitting in closets and holding doors open.

Comments

What about prescriptions? Or how many times will we have to go back because the patient changed their mind and now wants to go the real ED? This is a bad idea. It would create more problems than solve them.

“Not to mention that some people won’t want complete strangers to set up cameras and microphones in their houses or places of business. Their is that whole expectation of privacy thing.”With a cellular phone call, people intercept the call, but may not have any specific information to tie to any particular patient. I don’t give the patient’s name or address when calling in. With a scanner, they may be able to piece this together, but with video that accompanies the full medical report, nobody will have to guess about the identity of the person being described – they can see the patient.I would love to use a line like, “Now show the doctor that rash again and smile for all of the people getting this by email.” Or not. :-)The reason for this is that Tucson does not trust their medics to do much without a mother-may-I phone call. This is just digging their heels deeper, so they can get video of the baby steps.Let’s hope that lawyer/medic doesn’t need the services of EMS, now that he has moved out there. Critical judgment is learned by using it – something the doctors in charge seem not to understand.

Is there room for EMS “telemedicine”? Perhaps, but not in Tuscon IMHO, nor in any other part of the US where there is less than 1 hour transport (by ground or air)._IF_ EMS could find a way to deal with reimbursement (other than cardiac arrests and treated/released hypoglycemia, Medicare, Medicaid, and most 3rd party payors won’t spend a penny), there may be some benefit to this technology in rural areas where ALS providers are not readily available, and where “ER” docs are not as busy.So…someday there may be some benefit in the deep rural reaches (NPS ranger/EMTs for example?), but it’s technology that’s essentially worthless in the urban/suburban area.

Much of the original work on telemedicine as a concept was done by the US military. Which makes a fair amount of sense, but that sense doesn’t translate easily to the civilian market. Rogue Medic, privacy concerns aren’t the issue since cell phones are pretty much unmonitorable without a lot of expensive equipment. I’d also think that any information transmitted over the Internet would be encrypted. It’s the utility, or rather lack thereof, that concerns me.

TOTWTYTR,Cell phone signals are supposed to have some sort of encryption, aren’t they? Expecting the signals to be encrypted and work properly may be giving them too much credit. You, being the technology aficionado would know these better than I would.I agree that the privacy issues are not the main problem, but feel that there need to be as many obstacles to this as possible.Dr. YouTube is an indication of shortsighted people not trusting medics, rather than preparing them to use critical judgment, encouraging them to use critical judgment, and then developing that use of critical judgment for the benefit of the patient.This is only a demonstration of a lack of critical judgment on the part of their medical director and the medical director’s cronies.This is more of a deus ex machina solution to the problem of medical oversight. It doesn’t work very well in fiction, because it is so silly. In practice it loses none of the silliness.

Cell phones now use digital signals which are not receivable by commonly available “police” scanners. Equipment to monitor them is restricted to service centers and some law enforcement agencies. Which is not to say that some techno geek somewhere didn’t build his own receiver. However, that’s not going to be commonly done and certainly not going to be sold commercially since there are laws prohibiting it. I agree with you on the larger issue, which was my original point. At the least it diverts money that should go into educating prehospital personnel. It also is a crutch to keep lazy medical directors and managers from having to actually direct and manage.

All About Me

After a long career as a field EMS provider, I'm now doing all that back office stuff I used to laugh at. Life is full of ironies, isn't it?
I still live in the Northeast corner of the United States, although I hope to change that to another part of the country more in tune with my values and beliefs.
I still write about EMS, but I'm adding more and more non EMS subject matter.
Thanks for visiting. Read More…